Breast Cancer Patients, Research Paper Example

Breast cancer patients present a number of clinical characteristics pertaining to specific needs, both psychosocial and sexual in nature. The effects of the treatment often lead many breast cancer patients to feel reduced sexual desires and responsiveness, as well as body image problems. The purpose of a support group, then, is to ensure the provision of all of these needs in a supportive and relational context, thereby equipping the women to better handle their recovery.

The need for a support group for women dealing with the effects of breast cancer is indeed considerable. Body image and sexual problems, in particular, are some of the most commonly-reported issues for women dealing with the effects of breast cancer (Fobair et al., 2006, p. 579). Both of these are dependent upon vitality and concomitant ability to function in an accustomed manner, and thus, both are compromised by the effects of breast cancer and treatment (p. 580). These are foundational characteristics of the target population, breast cancer patients, and they define no small part of their seminal concerns in therapy.

Body image concerns are the first improved outcome clients should expect from the group therapy. The effects of chemotherapy, in particular, can be devastating: hair loss, “pallor, weight gain, nausea and vomiting, and fatigue” are all considerable issues for breast cancer patients’ sexual functioning, particularly in younger women (Bakewell & Volker, 2005, p. 698). Fobair et al. (2006) found that amongst their participants, treatment by mastectomy was common (55%), as well as treatment by chemotherapy (59%) (p. 585). The ramifications for these women’s health and well-being were considerable: irregular or stopped menstrual periods were common, as were hair loss, nausea, concerns of weight gain or loss, and hormonal symptoms such as vaginal dryness (p. 585). Unsurprisingly, body image problems pertaining to attractiveness and femininity were reasonably common amongst the respondents: 33% reported “two or more body image problems some of the time”, while 17% reported “at least one problem much of the time” (p. 586). There was a low incidence of serious problems, although body image issues for those that were sexually active were correlated with concerns about attractiveness, partners’ difficulties in relating to respondents’ own feelings, and difficulties with mental health and self-esteem (p. 588).

Psychological stress, such as depression and anxiety, takes a quite significant toll on sexual functioning for women in general (Henson, 2002, pp. 262-263). This is particularly an issue because anti-depressants have been known to make sexual dysfunction more severe, not less (p. 263). And the literature indicates that this is a significant area of need for breast cancer patients, who frequently experience “anxiety or depression or both”, with attendant consequences for sexual functioning (p. 263). For breast cancer patients, the effects of depression or anxiety or both on sexual functioning include feelings of less attractiveness, reduced interest in sexual congress, and stress regarding loss of hair (p. 263).

Problems with lack of sexual interest and arousal were also reported by Fobair et al. (2006) for the two-thirds of those who were active in sexual congress, as well as ability to experience sexual enjoyment and orgasm (p. 586). Improved sexual interest, arousal, and functioning, then, should be another improved outcome that the participants should expect from the group therapy. Concerning the one-third of the women who were not sexually active, the reasons for this included lack of interest; physical problems “that made sexual relations difficult or uncomfortable”, and tiredness (pp. 578-588). The problems and issues reported by participants are certainly considerable, and evince a great need for treatments to address patients’ needs in coming to grips with symptoms that they often find diminishing of their sense of attractiveness, femininity, and sexuality, as well as problems with communication and understanding that arise with their partners (pp. 590-592).

In light of the above, it should come as no surprise that the actual cancer treatment itself can in fact contribute to patients’ increased sexual dysfunction, on a number of different levels. Radical mastectomies can precipitate psychosocial and sexual issues for breast cancer patients, including lower rates of sexual congress and inability to achieve orgasm: some 21-30% of patients experience such problems (Henson, 2002, p. 263). These problems also tend to be exacerbated whenever they are concomitant with other psychosocial and sexual issues, including “preexisting marital difficulties, a poor body image, sexual dissatisfaction, lower educational level,” and having undergone chemotherapy (p. 263).

Significantly, breast conservation and breast reconstruction is associated with significantly improved psychosocial and sexual outcomes amongst breast cancer patients, including better preservation of body image and concomitant evaluation of one’s own sexual attractiveness (Henson, 2002, p. 264). However, these procedures are not without their shortcomings, and some researchers have found that they either do not have a positive impact on patients, or that they pose issues of their own, including scarring and lack of sensation in the affected tissues (pp. 264-265). Indeed, expectations that breast conservation surgery with lumpectomy, as well as improved reconstruction, would result in reduced incidence and severity of sexual dysfunction have proven unfounded and unsupported by the evidence (Bakewell & Volker, 2002, pp. 697-698). Body image considerations and comfort in a variety of garb are better amongst those who have undergone a lumpectomy as opposed to a mastectomy; however, the loss of sensitivity in the affected area can be extremely troubling to patients (p. 698). Adjustment to such changes typically takes about one to two years (p. 698).

With radiation therapy, patients’ concerns and issues are fewer and generally less severe (Bakewell & Volker, 2005, p. 698). Radiation therapy typically produces only localized, temporary side effects (p. 698). More specifically, body image considerations, notably skin changes such as “radiation tattoos, erythema, and burns” are temporary, usually no more than mildly distressing, and generally dissipate within months of the completion of treatment (p. 698). However, in some cases, side effects of radiation can be much longer-lasting, and can compromise sexual functioning (p. 698).

Despite a considerable literature evincing support for the idea that mastectomies pose considerable problems for breast cancer patients with regards to perceptions of sexual attractiveness and femininity, and thus pose significant risks of sexual dysfunction, Schover (1991) argued that far more important factors influencing sexual functionality include “overall psychological health, relationship satisfaction, and pre-morbid sexual life” (p. 112). The majority of patients, Schover noted, adjust well to the effects of a mastectomy, and breast conservation appears to have no more than a slight impact on quality of life (p. 113).

In order to address concerns about sexual functionality, Schover (1991) recommended, patients should be queried regarding normal sexual functionality for them, in order to ascertain which patients may require more attention and help (p. 118). Schover’s advice affords many sound strategies for integrating these research-based interventions into the course of group therapy treatment. As Schover explained, women with sexual and/or relationship problems are far more at risk for sexual dysfunction as a consequence of breast cancer treatment: women who are not in a committed relationship, or who are in an unhappy one, are particularly vulnerable (p. 118). So too are younger women, women who wish to beget children or at least more children, and those with pre-existing sexual dysfunctions and/or “a history of sexual trauma” (p. 118).

Since emotional and relationship support are very important for breast cancer patients who are at risk for sexual dysfunction, it is advised to involve the partner whenever possible: this can further facilitate communication about sexual relations for the couple (Schover, 1991, p. 118). For women who are not married or otherwise in a committed relationship, Schover explained, support groups are ideal, as is individual counseling: they can provide helpful emotional and social support, which is absolutely vital for these patients (p. 118).

It is also very important to provide patients with helpful insights, suggestions, and information regarding a resumption or initiation of sexual activity after diagnosis and, once achieved, treatment (Schover, 1991, p. 118). Different patients will have different needs and preferences, but Schover recommends that topics such as “whether to get used to openness about nudity or to increase comfort by concealing the site of breast surgery with a breast prosthesis or lingerie” (p. 118). Other sexual functioning issues, including vaginal dryness, should also be discussed (pp. 118-119). Moreover, communication is key: patients should be encouraged and equipped to communicate with current or prospective partners regarding sexual functioning issues (p. 119). Finally, clinicians should also remember that older women are often not asexual, and their needs and desires in this regard should be taken into account as well (p. 119).

More clues about how to integrated research-based evidence and interventions into group therapy practice come from Stephenson and Meston (2010), who assessed the question of what factors mediate betwixt sexual functioning and sexual distress; inasmuch as not all factors pertinent to the impairment of sexual functioning cause sexual distress, this is certainly a salient inquiry (p. 3683). What the researchers found was a significant correlation between levels of relational intimacy and attachment anxiety on the one hand, and various diverse aspects of sexual functioning and sexual distress on the other (p. 3687). Intimacy, attachment anxiety, and sexual functioning, in particular, were all intertwined and significantly related to each other (p. 3687). Functioning and distress, in particular, were correlated at “low levels of intimacy… and high levels of attachment anxiety… such that worse functioning was related to increased distress” (p. 3687).

High levels of sexual pain were also “likely to be associated with increased distress in low-intimacy versus high-intimacy relationships, especially for anxiously attached women” (Stephenson & Meston, 2010, p. 3687). Thus, the key factors are both relational intimacy and individual attachment anxiety: both have significant and foundational roles in moderating a number of aspects of sexual functioning on the one hand, and sexual distress on the other (p. 3688). These are certainly areas which should be addressed in group therapy, inasmuch as they are of such considerable importance.

As with anything that pertains to sexual function and dysfunction, the effects of breast cancer are far-reaching in their ramifications for patients’ relationships with intimate partners (Ming, 2002, p. 37). Improved communications and understanding with intimate partners, then, should be a third improved outcome that participants in the group should expect. As Ming explained, patients’ reactions to mastectomy, in particular, may be expected to have an impact on their husbands’ reactions, which in turn exert still further influence on the patients, and so on (p. 38). Thus, the reactions of both partners must be considered together, inasmuch as they both contribute to the dynamic of sexual functioning between them (p. 38). In particular, perspective-taking is of importance here: perspective-taking is a specific kind of empathy, one that entails looking at the world from the perspective of another (p. 38). Perspective-taking of both self and partner within the context of a marital relationship may be expected to be correlated with either partner’s ability to adjust to the effects of breast cancer (p. 38).

Ming (2002) found that many breast cancer patients had perceptions of less attractiveness, as well as dissatisfaction with appearance, and greater preoccupation with sexual appeal (p. 42). The results were similar amongst the husbands that were interviewed: the husbands expressed high rates of finding their wives less attractive, being dissatisfied with their wives’ appearances, and thinking about their wives’ sexual appeal more often (p. 42). However, a particularly noteworthy finding was that better self perspective-taking amongst the breast cancer patients, better perception of their husbands’ perspective-taking, and lower rates of psychological distress were all correlated with significantly better marital adjustment (p. 42). Unsurprisingly, too, the marital adjustment of the breast cancer survivors was positively associated with that of their husbands (p. 42). For their part, much the same was true of the husbands: those with “better self perspective-taking… more positive perception of their wives’ perspective-taking… less psychological distress… and more positive perception of their wives physical appearance” all had higher rates of marital adjustment (p. 42).

In the second study, Ming (2002) found that although only 15 patients indicated deterioration of their marriages as a result of the effects of breast cancer, with another 45 indicating that it had remained the same, in actuality even these 45 cases presented certain problems with marital adjustment to the changed circumstances (p. 45). These marital adjustment problems comprised six themes, including: “(1) lack of understanding, (2) sexual upset, (3) lack of support, (4) irritable mood, (5) body disfigurement due to mastectomy, and (6) extra-marital affair” (p. 45). A lack of shared understanding between patients and their husbands was by far the most common of these themes, and included very significant problems with a lack of communication about the issue (pp. 45-46).

The upset and disruption of normal sexual functioning was second in frequency, for the following six reasons: “(1) changed physical appearance due to mastectomy, (2) decreased sexual desire, (3) irrational belief, (4) afraid to become pregnant, (5) fatigue, and (6) pain” (Ming, 2002, p. 46). For the husbands’ part, their issues were comprised by four categories, namely “(1) psychological distress, (2) marital adjustment problem, (3) activity level reduction, and (4) physical discomfort” (p. 46). Again, poor communication contributing to a lack of understanding, as well as sexual upset were major issues for husbands (pp. 46-47). Two other issues encountered by husbands were irritability on the part of their wives and a lack of support from them (p. 47).

Finally, as Ming (2002) observed, marital adjustment was a cardinal concern for both wives and husbands (p. 47). An especially interesting finding is that what determined the wives’ ability to adjust in their marriage was not their own perceptions of their appearance, but rather how they perceived their husbands’ perspective-taking, and their husbands’ own attitudes about their attractiveness (p. 47). This is an important conclusion, inasmuch as it speaks to a possible recourse for treatment: helping breast cancer patients to evaluate their partners’ perspective-taking and communicate their needs to them, and involving partners in the process of communication and perspective-taking as well.

Kriss and Kraemer (1986) evaluated the effects of group therapy for breast cancer survivors who had undergone mastectomies, assessing both self-perception and sexual functioning, including sexual receptivity, sexual activity, and sexual adjustment (pp. 441-442). The treatment was conducted in groups of 8 to 12 women, led by a trained family therapist with a specialty in sexual disability (pp. 442-443). Prior to the treatment, the mastectomy treatment group had markedly lower scores for “positive affect, sexual receptivity, and sexual adjustment” than the control, non-mastectomy group (pp. 443-445). Notably and unsurprisingly, they expressed high rates of aversion and dislike for the amputated breast region (p. 445). After one year of treatment, the post-mastectomy treatment group evinced “small but statistically significant improvement in positive affect scores and significant improvement in sexual adjustment” (pp. 445-446).

However, in many ways the results of this study were a disappointment: there was a lack of significant improvement in the breast cancer survivors’ attitudes towards the amputated breast region, and there was no change for both “sexual receptivity to partners” and frequency of sexual activity (Kriss & Kraemer, 1986, p. 446). Clearly, something more is needed to address breast cancer survivors’ psychosocial and sexual functioning needs. As Bakewell and Volker (2005) explained, one of the most important needs of breast cancer patients is communication with their partners, who may seek to avoid communication in an effort to protect them, which can in turn lead to misunderstandings that can cloud the relationship (p. 700).

Milbury and Badr (2012) evaluated two different major kinds of communication patterns between breast cancer patients and their spouses: mutual constructive (MC) communication, characterized by free and open discussion of issues pertaining to the cancer, and demand-withdraw (DW) communication, characterized by a pattern of one partner pressuring the other to engage in communication about the cancer, and the other partner withdrawing (p. 2). The former, unsurprisingly, has been shown to correlate with higher levels of satisfaction and adjustment in marriage, leading to lower levels of psychological distress and better mutual support between both spouses (p. 2).

What Milbury and Badr (2012) found was that there is a significant and interesting interaction “between sexual problems, MC communication, and social role” (p. 4). Thus, patients with higher rates of sexual dysfunction and low levels of MC communication also had higher levels of depressive symptoms (p. 4). However, patients with high levels of sexual dysfunction who also had a great deal of MC communication with their spouses had far lower rates of depressive symptoms (p. 4). For partners, the pattern was a bit different: high incidence of MC communication did not have the same anti-depressant effect when their spouses also had high levels of sexual problems (p. 4). Nonetheless, in cases wherein the partners had low rates of sexual dysfunction, higher levels of MC communication did have an anti-depressant effect on them (p. 4).

The patterns of demand-withdraw (DW) communication were the converse of those involving MC communication: for the breast cancer patients, higher levels of DW communication were correlated with higher levels of depression when the DW communication was concomitant with sexual dysfunction (Milbury & Badr, 2012, p. 4). Similarly, for the partners, low levels of DW communication were not enough to exert an anti-depressant effect in cases wherein their spouses, the breast cancer patients, had high levels of sexual problems: only when the partners had low levels of sexual problems was the correlation with reduced depressive symptoms a significant one (pp. 4-5).

Group psychosocial support is a particularly efficacious treatment intervention for breast cancer patients. Goodwin et al. (2001) evaluated the impact of weekly group intervention meetings, each lasting 90 minutes, comprised of groups of 8-12 women led by an experienced specialist, such as a psychiatrist, psychologist, social worker or nurse clinician (p. 1720). The intervention group evinced substantial improvements in moods, including lower rates of depression, dejection, tension, anxiety, confusion and bewilderment (p. 1722). The intervention group also helped to reduce the incidence of severe pain, sometimes quite significantly (p. 1722). Finally, the median survival rate was higher in the intervention group (17.9 months) as opposed to the control group (17.6 months) (p. 1723).

As Lugton (1997) explained, the main concern with social support is the maintenance and changing of identities (p. 1186). The self-concept and identity maintenance are of the most profound and foundational importance, and these needs can be ministered to in a support group (pp. 1186-1187). In particular, the group can provide the necessary social support to reduce the stress of the breast cancer diagnosis by helping the patients to find it less overwhelming, and helping the members to “maintain or change their identities” in accordance with the exigencies of the circumstances (p. 1187). Reducing the threat to identity is important too, and this can be done by means of coping with anxiety and depression (p. 1187).

Through social support, breast cancer patients can navigate the crisis that the diagnosis can pose by changing their identities to a certain degree (Lugton, 1997, p. 1187). Changes to the self-concept are the way to do this: by examining the structure of the self-concept and accepting the need for changes, breast cancer patients can make those changes and adjust the self-concept accordingly (p. 1187). Along the way, they face needs for emotional support, companionship, practical help, opportunities for confiding, experiential support, and sexual identity support, all of which the group setting can address (p. 1187).

As Schover (1991) explained, counseling therapy is not always sufficient to achieve the desired aims (p. 119). In such cases, sex therapy may be the preferred recourse for addressing patients’ needs (p. 119). Although extremely controversial, sexual therapy is designed towards an authentic treatment end, that of overcoming sexual problems, including some that are very much of interest to breast cancer patients, such as anorgasmia and loss of sexual interest (Lowry & Lowry, 1975, p. 229). The ethical considerations, to be sure, are considerable: first and foremost, all sex therapy involves considerations of ethical issues pertaining to physical and psychological intimacy between the therapist and the patient (p. 229).

Psychological intimacy includes the fact that sex therapy may necessitate the patient sharing with the therapist details pertaining to their sexual fantasy life, which are often very intimate and private indeed (Lowry & Lowry, 1975, p. 230). Here, the most important thing is for the therapist to encourage the patient to open up about broad and general themes, while keeping private any details or particulars they do not wish to share (p. 230). Psychological transference is another concern: this involves patients transferring feelings that they have towards another figure in their life to the therapist (p. 230). With patients that have partners, the most important thing is to strengthen the bond between the partners, rather than replacing it with one between therapist and patient (p. 230). In some cases this may necessitate the therapist seeing both partners at the same time (p. 230). Another expedient is the use of a co-therapist, such that there are two therapists, one per gender: each can facilitate and provide support for the client who is of their gender (p. 230). This format is well-attested as an effective one (p. 230).

For patients who lack a partner, Lowry and Lowry (1975) recommended a controversial alternative: a surrogate or replacement partner (p. 231). As the authors explained, these surrogates “participate in the treatment by providing sexual opportunities and then later consulting with the psychological counselor” (p. 231). This approach is fraught with ethical pitfalls, to be sure: it may enable patients who have difficulties in this area to avoid resolving them on their own, since paid partners are simply doing their jobs, which can in turn exacerbate associated issues pertaining to sexual functioning (p. 231). Accordingly, this approach should probably be avoided whenever possible (p. 231).

With regards to anorgasmia, which is often a symptom of breast cancer patients, secondary anorgasmia may also be “either cause or effect of a disappointing marriage relationship” (Lowry & Lowry, 1975, p. 234). Accordingly, the best approach to use seems to be that of having a female therapist assist the woman in the process of “identifying what she needs in order to have function restored” (p. 234). As for the husband, a male therapist can assist him in ascertaining how to provide the sort of emotional support that he needs to provide in order to restore the health of the marriage or other relationship (p. 234). Primary anorgasmia, on the other hand, appears to be best resolved through group therapy, using a goal-oriented group method (p. 234). Overall, the group emphasizes “caring and sharing”, with much facilitation by group leaders, in order to increase the efficacy of treatment outcomes (p. 235). Indeed, treatments for this form of anorgasmia are very successful, with up to 91 percent of patients reporting success within the course of the treatment (pp. 234-235).

As regards the formation of the group, and the pertinent issues for the selection of members, the cardinal imperative is a consideration of the needs of each individual potential applicant, and the character and direction of the group itself (Jacobs, Masson, Harvill, & Schimmel, 2012, p. 73). Naturally in this case, all applicants should be women who are dealing with the effects of breast cancer, but more specifically, the aims of this group concern body image, sexual functioning, and communication issues with partners. As such, these concerns will guide my screening process (p. 73). The group should also be kept relatively small, in order to facilitate community and sharing: I want all of the participants to be able to feel free to participate, and to have plenty of opportunities to get to know each other over the course of the group therapy.

Corey (2008) recommended that leaders of groups spend time with members after the first round of screening, when a number of applicants have been recruited, in order to ascertain if they should be included in the group or not (p. 68). The key thing here is, again, a consideration of goals: what goals and objectives does each applicant bring to the table, and are these compatible with the overall aims of the group or not? Reluctance and defensiveness are not good reasons for screening someone out of a group: after all, group participation could help them to overcome these issues and be more confident and forthcoming (p. 68). That said, there are certain personality issues that do provide legitimate grounds for exclusion, such as unpleasant and domineering personality types (p. 69). Such individuals may threaten to drain all of the energy from a group, or they may seek to monopolize and control it; either type should be avoided at all costs, in order to ensure that the groups are productive, friendly, supportive and helpful (p. 69).

Group cohesiveness is a major tenet of group therapy theory, as Yalom and Leszcz (2005) explained: within group therapy practice, group cohesiveness is like the relationship between client and practitioner in individual therapy (p. 53). As such, this cohesiveness must be secured and nurtured, albeit not at the cost of individual well-being and treatment outcomes (p. 53). A strong bond between the clients and the therapist is also an essential, inasmuch as this can, in and of itself, help to dispel depressive beliefs and symptoms (p. 54).

Ethical considerations with group therapy differ somewhat from those of individual therapy, though there are, to be sure, many parallels. They are inextricable from issues pertinent to training levels and qualifications, and thus will be addressed together. As Corey, Corey, and Callanan (2010) explained, it is essential from an ethical point of view for group leaders to evince a willingness to do what they are asking the members of their group to do: engage in self-analysis and discovery (p. 482). This is of the most profound importance, because group leaders need to lead by example. My own background in this has well prepared me for such an endeavor, inasmuch as this is not my first experience counseling a group.

Group counseling also poses the prospect of more multicultural issues: whereas with individual therapy, therapist and patient will have, at most, two different cultural perspectives to work from, with a group the cultural diversity can be much greater (Corey et al., 2010, p. 484). Accordingly, it is very important for therapists to consider this, and ensure that due consideration is given to diverse cultural frameworks and traditions, in order to secure a culturally sensitive and appropriate group therapy situation (p. 484).

Another ethical issue pertains to group dynamics, and members’ own respective feelings of what they are and are not willing to share (Koocher & Keith-Spiegel, 2008, p. 132). Whereas with individual therapy, the therapist only has to work with one patient, and can better work within their comfort level, with group therapy the therapist must negotiate with the fact that different members will have different boundaries and different levels of comfort with sharing personal details, especially those of a sexual nature in this case (p. 132). Accordingly, the therapist must not pressure participants to reveal more than they wish: the therapist can encourage, assist, and help, but should never pressure (p. 132). Again, this is something that I have had experience with already, having led group counseling and therapy sessions before; accordingly, I feel prepared to undertake it.

In conclusion, the needs of breast cancer patients are considerable, and range from body image problems and perceived reduced sexual attractiveness to problems with reduced sexual functioning, arousal, and satisfaction. Communication with partners is another important issue, since partners often have difficulty understanding the psychosocial and relational needs of women with breast cancer. Through supportive group therapy, breast cancer patients can gain psychosocial support from other patients and from a trained therapist, who can help them to ascertain the ways in which they need to adjust in order to deal with the challenges they confront.

References

Bakewell, R. T., & Volker, D. L. (2005). Sexual dysfunction related to the treatment of young women with breast cancer. Clinical Journal of Oncology Nursing, 9(60, pp. 697-702. DOI: 10.1188/05.CJON.697-702

Corey, G. (2008). Theory & Practice of Group Counseling. Belmont, CA: Thomson Higher Education.

Corey, G., Corey, M. S., & Callanan, P. (2010). Issues and ethics in the helping professions. Belmont, CA: Brooks/Cole.

Fobair, P. et al. (2006). Body image and sexual problems in young women with breast cancer. Psycho-Oncology, 15, pp. 579-594. DOI: 10.1002/pon.991

Goodwin, P. J., et al. (2001). The effect of group psychosocial support on survival in metastatic breast cancer. The New England Journal of Medicine, 345(24), pp. 1719-1726.

Henson, H. K. (2002). Breast cancer and sexuality. Sexuality and Disability, 20(4), pp. 261-275.

Jacobs, E. E., Masson, R. L., Harvill, R. L., & Schimmel, C. J. (2012). Group counseling: Strategies and skills. Belmont, CA: Brooks/Cole.

Koocher, G. P., & Keith-Spiegel, P. (2008). Ethics in psychology and the mental health professions. New York: Oxford University Press.

Kriss, R. T., & Kraemer, H. C. (1986). Efficacy of group therapy for problems with postmastectomy self-perception, body image, and sexuality. The Journal of Sex Research, 22(4), pp. 438-451.

Lowry, T. S., & Lowry, T. P. (1975). Ethical considerations in sex therapy. Journal of Marriage and Family Counseling, pp. 229-236.

Lugton, J. (1997). The nature of social support as experienced by women treated for breast cancer. Journal of Advanced Nursing, 25, pp. 1184-1191.

Milbury, K., & Badr, H. (2012). Sexual problems, communication patterns, and depressive symptoms in couples coping with metastatic breast cancer. Psycho-Oncology, pp. 1-9. DOI: 10.1002/pon.3079

Ming, V. M. W. (2002). Psychological predictors of marital adjustment in breast cancer patients. Psychology, Health & Medicine, 7(1), pp. 37-51. DOI: 10.1080/13548500120101540

Schover, L. R. (1991). The impact of breast cancer on sexuality, body image, and intimate relationships. CA-A Cancer Journal for Clinicians, pp. 112-120.

Stephenson, K. R., & Meston, C. M. (2010). When are sexual difficulties distressing for women? The selective protective value of intimate relationships. Journal of Sexual Medicine, 7, pp. 3683-3694. DOI: 10.1111/j.1743-6109.2010.01958.x

Yalom, I. D., & Leszcz, M. (2005). The theory and practice of group psychotherapy. New York: Perseus.

Websites:

http://bcsupport.org/

http://www.cancer.org/cancer/breastcancer/index?gclid=CLuemdua3bMCFaU5QgodCH4AmQ

http://www.agpa.org/group/ethicalguide.html

http://www.groupsinc.org/pubs/gs_0499.html

http://www.cancercenter.com/after-care-services/encouraging-support.cfm?source=GOOGLEWE&channel=paid%20search&c=paid%20search:Google:Google%20-%20Western%20Core%20Terms:General%3A+Cancer+Support:cancer+support+groups:Broad&OVMTC=Broad&site=&creative=4341245301&OVKEY=cancer%20support%20groups&url_id=129216981&adpos=1t1&gclid=CK_Tl6ya3bMCFYF7Qgod_RIAQg

http://cancerhopenetwork.org/index.php?page=findamatch&gclid=CNKP-a2a3bMCFeGDQgodORAAgg

http://www.cancersupportcommunity.org/?gclid=CKTtva-a3bMCFal_QgodLzsAtA